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And that means full scope of practice as primary care providers. Medical societies hate the idea and think that nurse practitioners need to be tethered securely to a physician office in order to ensure top-notch care. Nurse practitioners counter that they can help shore up primary care.

With accumulators, the value of any copay assistance cards or coupons does not count toward out-of-pocket medicine costs that are applied toward deductibles. It’s a cost-shifting tool that’s facing pushback from patients, providers, and others saying that accumulators will hurt public health.

The pay-for-value movement could justify rewarding—and punishing—doctors based on quality scores. Problem: Hardly anyone likes the current ways quality is measured, especially physicians. Few believe that Medicare’s Merit-based Incentive Payment System (MIPS) will clear things up. In fact, it might cause more confusion.

Bereft of his own connections, President Trump recruited from conservative think tanks to fill health care positions in his administration. Many of them have Koch brother connections, and their agendas often run counter to Trump campaign rhetoric—and his impulses.

It is often an on-again, off-again disease, distressing partly because it is so un­predictable. It may defy the conventional wisdom about adherence and early treatment. And escalating prices have undercut cost-effectiveness arguments for the drugs that can keep it in check. Multiple sclerosis is a managed care nightmare.

Democrats are running on Medicare for All—or extending the seniors’ program to the merely middle-aged—or resurrecting a ‘public option’. Republicans say Medicare expansion would mean government intrusion and inefficiency. But politics aside, how would these Medicare expansions work?

Pharma and Trump administration officials decry them as backroom deals. But payers and PBMs say rebates are an important negotiating tool with drugmakers. Take it away and drug expenditure will go up even faster.